Investigacin y utilizacin clnica de clulas

madre procedentes de tejidos adultos

In memorian

Clulas = Medicamento

Directivas comunitarias (BOE 12 de diciembre de 2003) sobre

medicamentos de terapia celular somtica de origen humano
Nuevas normas para ensayos clnicos en los que ya se contemplan
los ensayos clnicos con medicamentos de terapia celular somtica
(BOE 7 de febrero de 2004)
Real Decreto 176/2004 (B.O.E. 31/01/04) en el que se aprueba el
Estatuto del Centro Nacional de Transplantes y Medicina
Regenerativa

Medicamentos de Terapias Avanzadas

Clinical Trial Process

Objetivos principales de los

ensayos clnicos
FASE I : Estimacin inicial de seguridad y tolerabilidad.

FASE II: Determinacin de eficacia en la indicacin propuesta

FASE III: Demostrar/confirmar eficacia (eficiencia) en la
indicacin propuesta

FASE IV: Completar el conocimiento de la relacin beneficioriesgo

Identificar reacciones adversas de baja frecuencia.

Determinar la eficiencia del tratamiento.

Ensayos clnicos en terapia celular

(clinicaltrials.gov)
Ensayos
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
5000
4500
4000
3500
3000
2500
2000
1500
1000
500
0

Ensayos

Clinical trials using Stem Cells

(clinicaltrials.gov)

SPAIN: 134

Clinical trials using Stem Cells

Open Studies:1775 (October2012)

Phase III

201

Phase II

907

phase I

553

200

400

600

800

1000

Phase III Completed Studies

Bioseguridad y resultyados:

11

CURVA DE GARNET

Cell Therapy clinical trials

Therapeutic areas
(Non hematopoietic cells)
Taking into account cells different from hematopoietic cells

13
Source: Clinical trials.gov. Companies web pages

Stem Cells with Cardiac Potential

CSC

ESC/iPS

Acute and
chronic MI
ADSC

MO

MSC

MIOBLASTOS

Clinical Studies
Cell Types
BM, Adipose cells, SkM, EPC,
Cardiac Progenitors

Manufacturing
Culture, isolation, differentiation

Disease
Acute and Chronic MI

Delivery of the cells

Intracoronary, percutaneous,
surgical

Clinical Studies

Building a heart
Nat Med. 2008; 14:213-21

TCP-

PRP carrier celular

preop

postop

7m

11m

Tratamientos de las lesiones

focales: trasplante de condrocitos
autlogos

Lesiones Corneales
Agentes etiolgicos

Primarios
Hereditarios:
Aniridia, Stevens-Johnson
Neoplsicos:
Neoplasia intraepitelial
Degenerativos:
Pterigion recidivante
Secundarios
Fsicos: cidos, agresin trmica,
Traumatismos
Anoxia: Lentes de contacto
Inflamaciones crnicas

Tratamiento
Tratamiento
1. Restaurar la defensa de
la superficie ocular
2. Transplante autolgo de
limbo

3. Transplante alognico
de limbo
4. Transplante de
membrana amnitica

5. Transplante autlogo de
clulas progenitoras

Trasplante de CM Limbocorneales

Futuro: Cornea Artificial

Progenitores en la
insuficiencia heptica aguda

Nature, July 2013

Spinal Cord Injury: 127

Studies

How Stem Cells may help to a

Surgeon?

Revolutions in Surgery
1846-1982

Healing

Ulceras cutneas

Healing is a cell-based
process

+
May a stem-cells supplement improve
healing?

ENSEANZAS DE UN CICLO COMPLETO DE ENSAYOS

CLNICOS EN TERAPIA CELULAR

Fistula in Crohns Disease: a real problem of

wound healing due to auto-immune disease

Perianal discharge
Pain
Swelling
Bleeding
Diarrhea
Skin excoriation
External opening

Complex perianal fistula

An unmet need
Definition:

A complex perianal fistula is characterized by:

Affection of the anal sphincters
Multiple tracts
Associated with perianal abscess and/or connects an adjacent
structure
Recurrence

Current treatments dont

address unmet need

Cryptoglandular Disease

Crohnss Disease
Infliximab

Advanced Flaps
Author

Recurrence
(%)

Incontinence
(%)

Schouten 1999

25

35

Healing IFX (%)

Mizrahi 2002

45

Sonoda 2002

36,4

Van Koperen 2008

21

Present
1999

Sands
2004

55-38

36

Healing Placebo (%)

13

18

---

Recurrence IFX (%)

---

64

40

Recurence Placebo (%)

---

81

Author

37

Whats the best source for Stem Cells

to treat Surgical Diseases?

Alfa-actina

Stem Cells from Adipose Tissue

Advantages
Hematopoetic (bone marrow)

1986
1990

Intestine

Liver

1992

Skin

1993

1993

Muscle

Mesenchymal cells (bone marrow) 1999

1999

brain

MAPC (bone marrow)

2001

2001

Adipose
Grasa tissue

Pancreas

2003

2003

heart

Adipose derived mesenchymal stem cells:

Higher yield (between 100 and 1000 times higher yield than bone marrow)
BM stimulation is not required (G-CSF)

Expendable and accessible: Simple liposuction

Biosafety: No chromosomal alterations/ tumorigenic behavior after long term ex
vivo cultures
Wide range of potential applications
39

Cells extraction by liposuction

Local
anaestesia.(mepivacaina al
1%)
Little incisin (0,5 cm.)

Aesthetical value

Technologies involved in Adipose Derived

Stem Cells (ASC) Therapy
ASC Obtention

ASC
manipulation

Liposuction isolation

In vitro culture
ASC Implant
Cryopreservation

Cell expansion

Master
Cell
Bank

ASC Clinical Development in

fistula
2002

2003

2004

2005

2006

2007

2008

2009

2010

2012

2013

Preclinical
Proof of
Concept

Phase I

1 case
1 center

1 case
1 center

8 cases
1 center

CX601

FATT1

Phase III
Completed
Autologous

Ongoing
Allogenic

3 centers
10 cases

RVGF

50 cases
3 centers

Phase II

24 cases

1 center

10 cases
RVF
1 center

10 cases
ULTRA
1 center

207 cases

200 cases

20 centers

ADMIRE 30 center

FATT2

210 cases

22 centers

42

80 cases

FISPAC

5 centers

ASC Clinical Development in

fistula
2002

2003

2004

2005

2006

2007

2008

2009

2010

Preclinical

Proof of Concept

1 case
1 center

8 cases
1 center

Phase I

CX601

50 cases
3 centers

Phase II

FATT1

Phase III
Completed
Autologous

RVGF

Ongoing
Allogenic

207 cases
10 centers

FATT2

43cases
210

22 centers

24 cases
3 centers
10 cases
1 center

Clinical Proof of Concept

Successful cell treatment of a young woman with a recurrent
recto-vaginal Crohns fistula unresponsive to medical treatment

44

ASC Clinical Development in

fistula
2002

2003

2004

2005

2006

2007

2008

2009

2010

Preclinical

Proof of Concept

1 case
1 center

8 cases
1 center

Phase I

CX601

50 cases
3 centers

Phase II

FATT1

Phase III
Completed
Autologous

RVGF

Ongoing
Allogenic

207 cases
10 centers

FATT2

45cases
210

22 centers

24 cases
3 centers
10 cases
1 center

Phase I clinical trial

TRIAL SUMMARY
Trial Location

Start

La Paz Hospital, Madrid

Fistula closure
Phase I

Patients

Treatments

Rejection

Complete

Partial

April 2002

Enrollment
Design

Administration
Duration
Controlled
Endpoint
Results

5 patients (total of 8 fistulas)

Open Label; Feasibility / Safety
Study

Intralesional use
First evaluation of endpoint: 8
weeks
No
Complete closure/healing of the
fistula clinically assessed
75% success

NO SEVERE ADVERSE EVENTS

NO TUMOROGENIC EVENTS

46

ASC Clinical Development in

fistula
2002

2003

2004

2005

2006

2007

2008

2009

2010

Preclinical

Proof of Concept

1 case
1 center

8 cases
1 center

Phase I

CX601

50 cases
3 centers

Phase II

FATT1

Phase III
Completed
Autologous

RVGF

Ongoing
Allogenic

207 cases
10 centers

FATT2

47cases
210

22 centers

24 cases
3 centers
10 cases
1 center

Phase II clinical trial

General considerations

Multi-center:

Randomized

Three major hospitals in Madrid, Spain

Randomization performed by an independent

organization

Controlled

Control arm: fibrin glue as fistula tract sealant

(one of the elective procedures to avoid
conventional surgery)

Patient Selection:
Older than 18 years
Both sexes
Complex perianal fistula pathology
fulfilling some of the following
conditions:
Associated faecal incontinence
Risk factors of anal incontinence

Add-on trial

Treatment arm: Cx401administered

intralesionally and fibrin glue as tract sealant

Open-label, primary endpoint evaluated

by a blinded committee

Committee formed by three surgeons experts

in coloproctology not recruiting patients for the
study
Analyzed clinical and photographic data

At least 1 previous operation for a

fistulous disorder
Rectovaginal fistula
Crohns disease

Route of Administration:
Intralesional use:
in the fistula wall (*)
mixed with the fibrin glue

48

Phase II clinical trial

Design

Experimental
Treatment Group
Cx401 + Fibrin glue

Control Group
Fibrin glue

50
patients

Tract identification

Randomise

25 patients

25 patients
Cell inyection: cell
dose in the fistula wall

Experimental
Treatment Group
Cx401 + Fibrin glue

Control Group
Fibrin glue

cell dose in internal

opening

Curetage

24 patients (ITT) 25 patients (ITT)

Internal opening closure

Primary
Outcome

Secondary
Outcome
49

Tract sealant

Safety
Acute phase

Primary evaluation (eight weeks after last treatment) revealed 17 adverse

events with Cx401 and 11 with fibrin glue
Only 2 serious adverse events (SAEs) were observed with fibrin glue and 2
with Cx401
Not a single SAEs was related to Cx401

Group

Crohns disease

Description

Severity

Results

Causality

Fibrin glue

Yes

Crohns crisis and

intrabdominal abscess

Yes

In recovery

Not related

Cx401

No

Perianal abscess

Yes

Recovered

Not related

Cx401

No

Cholecystitis and
cholelithiasis.
Choledocholothiasis after
cholecystomy

Yes

In recovery

Not related

Fibrin glue

Yes

Perianal abscess

Yes

Recovered

Related
50

Administration of Adipose Derived Stem Cells was

effective in inducing healing in patients with complex
fistula-in-ano including Crohns disease, and this
procedure can be considered safe

70%

70%

Stem Cells. 2013 Feb 13. doi: 10.1002/stem.1357.

82%

ASC Clinical Development in

fistula
2002

2003

2004

2005

2006

2007

2008

2009

2010

Preclinical

Proof of Concept

1 case
1 center

8 cases
1 center

Phase I

CX601

50 cases
3 centers

Phase II

FATT1

Phase III
Completed
Autologous

RVGF

Ongoing
Allogenic

207 cases
10 centers

FATT2

54cases
210

22 centers

24 cases
3 centers
10 cases
1 center

FATT1 Non-Crohn Population

Efficacy 24 weeks COMMITTEE
All cases
No statistical significance
50
40
30
20
10
0
A (Cells Alone)

B (Cells+FibrinGlue)

C (FibrinGlue)

Efficacy 24 weeks COMITTEE

Why?
90

P<0.0001

80
70

60
50

All Cases

40

La Paz

30

Others

20

10
0

A (Cells Alone)

B (Cells+FibrinGlue)

C (FibrinGlue)

Patient distribution by Complexity Score and

center (Median)
9

P<0.001

8
7
6
5
4

La Paz

Others

Efficacy 24 weeks COMITTEE

90

80
70

Why?

60
50

Toda La Serie

40

La Paz

30

Otros

20

10
0

A (Cells Alone)

B (Cells+FibrinGlue)

C (FibrinGlue)

Technical survey

We detect a large numbers of mistakes during

the surgical procedure in others hospitals:
use of hydrogen peroxide (H2O2), cell shake,
cells spilling..

What have we learned?

Clinical Trials Peculiarities in Cell Therapy

This is a Living medicament and hence

a careful management is a key point.

Long Term Efficacy (Fistula Closed)

60

No statistical significance
50

40
FATT1

30

LTS (PP, begining)

20

LTS (PP, 24 w)

10
0

A (Cells Alone)

B (Cells+Fibrin Glue)

C (Fibrin Glue)

Capital Venture

Our Sponsor lost the interest

in autologous ADSCs

ASC Clinical Development in

fistula
2002

2003

2004

2005

2006

2007

2008

2009

2010

Preclinical

Proof of Concept

1 case
1 center

8 cases
1 center

Phase I

CX601

FATT1

Phase III
Completed
Autologous

Ongoing
Allogenic

3 centers
10 cases

RVGF

50 cases
3 centers

Phase II

24 cases

1 center

207 cases
10 centers

FATT2

63cases
210

22 centers

ASC Clinical Development in

fistula
2002

2003

2004

2005

2006

2007

2008

2009

2010

Preclinical

Proof of Concept

1 case
1 center

8 cases
1 center

Phase I

CX601

FATT1

Phase III

Autologous

Ongoing
Allogenic

24 cases
3 centers
10 cases

RVGF

50 cases
3 centers

Phase II

Completed

Allogenic Use
Cells Bank

1 center

207 cases
10 centers

FATT2

64cases
210

22 centers

Immunogenicity (ADSCs/Mesenchymal)
Privileged Cells
Other cell types

MSCs

Surface antigens

Surface antigens

High levels of MHC I (HLA-A, B, C)

Low levels of Mayor

Histocompatibility Complex Class I
(HLA-A, B, C)

MHC II: depending on cell type

Co-stimulatory molecules
Depending on cell type

CD55 and CD59: depending on cell

type

Lack of Mayor Histocompatibility

Complex Class II (HLA-DR, DQ, DP)
Lack of co-stimulatory molecules

Other Factors
Lack of IDO induction

CD40 (TNFR), CD80 (B7-1), CD86

(B7-2)

High levels of CD55 (DAF) and CD59

(Protectin) => protectors of complement
associated lysis

Other Factors
Strong IDO induction

Allogenic ASCs
Multicenter Phase I/IIa Study to assess
the safety and Efficacy of Expanded
Allogenic Adipose-Derived Stem Cells
(eASCs), for treatment of Complex
Perianal Fistulas in Crohns Disease.

Starting: December 2009

Results: December 2011

CX601

Percentage of subjects in whom at 12 and 24 weeks the

external openings of treated perianal fistula have closed Per
Protocol set
100
90
80
70

percentages

63,2
60
53,3
50

46,7

12
40

36,8

30

20
10
0
After 12 weeks
N=19

After 24 weeks
N=15
None

One
67

Allogenic ASCs
A Phase I/IIa Study to assess the safety
and Efficacy of Expanded Allogenic
Adipose-Derived Stem Cells (eASCs),
for treatment of Recto-Vaginal Fistulas
in Crohns Disease.

Starting: December 2009

Results: December 2011

CX601

Percentage of woman in whom at first doses and second

doses the recto vaginal wall have closed Per Protocol set

69

What happen if we repeated dose?

Why not more doses?
Excellent Safety profile
No incontinence risk
Its not a painful procedure

Cost?
Regulatory: Cells=Medicines
Why not together anti TNFs?

ASC Clinical Development in

fistula
2002

2003

2004

2005

2006

2007

2008

2009

2010

2012

2013

Preclinical
Proof of
Concept

Phase I

1 case
1 center

1 case
1 center

8 cases
1 center

CX601

FATT1

Phase III
Completed
Autologous

Ongoing
Allogenic

3 centers
10 cases

RVGF

50 cases
3 centers

Phase II

24 cases

1 center

10 cases
RVF
1 center

10 cases
ULTRA
1 center

207 cases

200 cases

20 centers

ADMIRE 30 center

FATT2

210 cases

22 centers

71

80 cases

FISPAC

5 centers

Where do we go?

Safety Profile Excellent

DOSE INCREASE

Cell Mortality

IMPROVING METHODS FOR DELIVERING

Soft effects
CELL INGENIERING

CELL IMPROVING WITH STIMULATING FACTORS

(BMPs,)

Tissue-engineered products contain

mixtures of the following
Biological components - cells
Can be genetically modified to behave a specific way
Chemicals

That tell the tissue to regenerate

A non-biological component
Polymer scaffold: Fibers, plastic, other natural
components
Gels

Building a trachea

Lancet. 2008; 372:2023-30

 Future is now here!

Building a bladder

Building a heart

Nat Med. 2008; 14:213-21

The future of stem cell therapy?

Portada revista TIME

(21 febrero 2011)

And then, how to use Cell Therapy in

Clinical Practice?
Only two ways:

1.- Clinical Trials

2.- Compassionate Use
Three exceptions for consolidated use
Condrocytes
Queratinocytes
Limbo-corneal cells

Muchas gracias!